Everyone occasionally feels blue or sad, but these feelings are usually
fleeting and pass within a couple of days. When a person has a depressive
disorder, it interferes with daily life, normal functioning, and causes pain for
both the person with the disorder and those who care about him or her.
Depression is a common but serious illness, and most who experience it need
treatment to get better.
Many people with a depressive illness never seek treatment. But the vast
majority, even those with the most severe depression, can get better with
treatment. Intensive research into the illness has resulted in the development
of medications, psychotherapies, and other methods to treat people with this
disabling disorder.
There are several forms of depressive disorders. The most common are major
depressive disorder and dysthymic disorder.
Major depressive disorder, also called major depression, is characterized by
a combination of symptoms that interfere with a person's ability to work, sleep,
study, eat, and enjoy once–pleasurable activities. Major depression is disabling
and prevents a person from functioning normally. An episode of major depression
may occur only once in a person's lifetime, but more often, it recurs throughout
a person's life.
Dysthymic disorder, also called dysthymia, is characterized by long–term (two
years or longer) but less severe symptoms that may not disable a person but can
prevent one from functioning normally or feeling well. People with dysthymia may
also experience one or more episodes of major depression during their lifetimes.
Some forms of depressive disorder exhibit slightly different characteristics
than those described above, or they may develop under unique circumstances.
However, not all scientists agree on how to characterize and define these forms
of depression. They include:
Psychotic depression, which occurs when a severe depressive illness is
accompanied by some form of psychosis, such as a break with reality,
hallucinations, and delusions.
Postpartum depression, which is diagnosed if a new mother develops a major
depressive episode within one month after delivery. It is estimated that 10 to
15 percent of women experience postpartum depression after giving birth.1
Seasonal affective disorder (SAD), which is characterized by the onset of a
depressive illness during the winter months, when there is less natural
sunlight. The depression generally lifts during spring and summer. SAD may be
effectively treated with light therapy, but nearly half of those with SAD do not
respond to light therapy alone. Antidepressant medication and psychotherapy can
reduce SAD symptoms, either alone or in combination with light therapy.2
Bipolar disorder, also called manic-depressive illness, is not as common as
major depression or dysthymia. Bipolar disorder is characterized by cycling mood
changes-from extreme highs (e.g., mania) to extreme lows (e.g., depression).
Visit the NIMH website for more information about
bipolar disorder.
People with depressive illnesses do not all experience the same symptoms. The
severity, frequency and duration of symptoms will vary depending on the
individual and his or her particular illness.
Symptoms include:
Persistent sad, anxious or "empty" feelings
Feelings of hopelessness and/or pessimism
Feelings of guilt, worthlessness and/or helplessness
Irritability, restlessness
Loss of interest in activities or hobbies once pleasurable, including
sex
Fatigue and decreased energy
Difficulty concentrating, remembering details and making decisions
Insomnia, early–morning wakefulness, or excessive sleeping
Overeating, or appetite loss
Thoughts of suicide, suicide attempts
Persistent aches or pains, headaches, cramps or digestive problems that
do not ease even with treatment
Depression often co–exists with other illnesses. Such illnesses may precede
the depression, cause it, and/or be a consequence of it. It is likely that the
mechanics behind the intersection of depression and other illnesses differ for
every person and situation. Regardless, these other co–occurring illnesses need
to be diagnosed and treated.
Anxiety disorders, such as post–traumatic stress disorder (PTSD),
obsessive–compulsive disorder, panic disorder, social phobia and generalized
anxiety disorder, often accompany depression.3,4 People experiencing PTSD are
especially prone to having co-occurring depression. PTSD is a debilitating
condition that can result after a person experiences a terrifying event or
ordeal, such as a violent assault, a natural disaster, an accident, terrorism or
military combat.
People with PTSD often re–live the traumatic event in flashbacks, memories or
nightmares. Other symptoms include irritability, anger outbursts, intense guilt,
and avoidance of thinking or talking about the traumatic ordeal. In a National
Institute of Mental Health (NIMH)–funded study, researchers found that more than
40 percent of people with PTSD also had depression at one-month and four-month
intervals after the traumatic event.5
Alcohol and other substance abuse or dependence may also co–occur with
depression. In fact, research has indicated that the co–existence of mood
disorders and substance abuse is pervasive among the U.S. population. 6
Depression also often co–exists with other serious medical illnesses such as
heart disease, stroke, cancer, hiv/aids, diabetes, and Parkinson's disease.
Studies have shown that people who have depression in addition to another
serious medical illness tend to have more severe symptoms of both depression and
the medical illness, more difficulty adapting to their medical condition, and
more medical costs than those who do not have co–existing depression.7 Research
has yielded increasing evidence that treating the depression can also help
improve the outcome of treating the co–occurring illness.8
There is no single known cause of depression. Rather, it likely results from
a combination of genetic, biochemical, environmental, and psychological factors.
Research indicates that depressive illnesses are disorders of the brain.
Brain-imaging technologies, such as magnetic resonance imaging (MRI), have shown
that the brains of people who have depression look different than those of
people without depression. The parts of the brain responsible for regulating
mood, thinking, sleep, appetite and behavior appear to function abnormally. In
addition, important neurotransmitters–chemicals that brain cells use to
communicate–appear to be out of balance. But these images do not reveal why the
depression has occurred.
Some types of depression tend to run in families, suggesting a genetic link.
However, depression can occur in people without family histories of depression
as well.9 Genetics research indicates that risk for depression results from the
influence of multiple genes acting together with environmental or other
factors.10
In addition, trauma, loss of a loved one, a difficult relationship, or any
stressful situation may trigger a depressive episode. Subsequent depressive
episodes may occur with or without an obvious trigger.
Depression is more common among women than among men. Biological, life cycle,
hormonal and psychosocial factors unique to women may be linked to women's
higher depression rate. Researchers have shown that hormones directly affect
brain chemistry that controls emotions and mood. For example, women are
particularly vulnerable to depression after giving birth, when hormonal and
physical changes, along with the new responsibility of caring for a newborn, can
be overwhelming. Many new mothers experience a brief episode of the "baby
blues," but some will develop postpartum depression, a much more serious
condition that requires active treatment and emotional support for the new
mother. Some studies suggest that women who experience postpartum depression
often have had prior depressive episodes.
Some women may also be susceptible to a severe form of premenstrual syndrome
(PMS), sometimes called premenstrual dysphoric disorder (PMDD), a condition
resulting from the hormonal changes that typically occur around ovulation and
before menstruation begins. During the transition into menopause, some women
experience an increased risk for depression. Scientists are exploring how the
cyclical rise and fall of estrogen and other hormones may affect the brain
chemistry that is associated with depressive illness.11
Finally, many women face the additional stresses of work and home
responsibilities, caring for children and aging parents, abuse, poverty, and
relationship strains. It remains unclear why some women faced with enormous
challenges develop depression, while others with similar challenges do not.
Men often experience depression differently than women and may have different
ways of coping with the symptoms. Men are more likely to acknowledge having
fatigue, irritability, loss of interest in once–pleasurable activities, and
sleep disturbances, whereas women are more likely to admit to feelings of
sadness, worthlessness and/or excessive guilt.12,13
Men are more likely than women to turn to alcohol or drugs when they are
depressed, or become frustrated, discouraged, irritable, angry and sometimes
abusive. Some men throw themselves into their work to avoid talking about their
depression with family or friends, or engage in reckless, risky behavior. And
even though more women attempt suicide, many more men die by suicide in the
United States.14
Depression is not a normal part of aging, and studies show that most seniors
feel satisfied with their lives, despite increased physical ailments. However,
when older adults do have depression, it may be overlooked because seniors may
show different, less obvious symptoms, and may be less inclined to experience or
acknowledge feelings of sadness or grief.15
In addition, older adults may have more medical conditions such as heart
disease, stroke or cancer, which may cause depressive symptoms, or they may be
taking medications with side effects that contribute to depression. Some older
adults may experience what some doctors call vascular depression, also called
arteriosclerotic depression or subcortical ischemic depression. Vascular
depression may result when blood vessels become less flexible and harden over
time, becoming constricted. Such hardening of vessels prevents normal blood flow
to the body's organs, including the brain. Those with vascular depression may
have, or be at risk for, a co–existing cardiovascular illness or stroke.16
Although many people assume that the highest rates of suicide are among the
young, older white males age 85 and older actually have the highest suicide
rate. Many have a depressive illness that their doctors may not detect, despite
the fact that these suicide victims often visit their doctors within one month
of their deaths.17
The majority of older adults with depression improve when they receive
treatment with an antidepressant, psychotherapy, or a combination of both.18
Research has shown that medication alone and combination treatment are both
effective in reducing the rate of depressive recurrences in older adults.19
Psychotherapy alone also can be effective in prolonging periods free of
depression, especially for older adults with minor depression, and it is
particularly useful for those who are unable or unwilling to take antidepressant
medication.20, 21
Scientists and doctors have begun to take seriously the risk of depression in
children. Research has shown that childhood depression often persists, recurs
and continues into adulthood, especially if it goes untreated. The presence of
childhood depression also tends to be a predictor of more severe illnesses in
adulthood.22
A child with depression may pretend to be sick, refuse to go to school, cling
to a parent, or worry that a parent may die. Older children may sulk, get into
trouble at school, be negative and irritable, and feel misunderstood. Because
these signs may be viewed as normal mood swings typical of children as they move
through developmental stages, it may be difficult to accurately diagnose a young
person with depression.
Before puberty, boys and girls are equally likely to develop depressive
disorders. By age 15, however, girls are twice as likely as boys to have
experienced a major depressive episode.23
Depression in adolescence comes at a time of great personal change–when boys
and girls are forming an identity distinct from their parents, grappling with
gender issues and emerging sexuality, and making decisions for the first time in
their lives. Depression in adolescence frequently co–occurs with other disorders
such as anxiety, disruptive behavior, eating disorders or substance abuse. It
can also lead to increased risk for suicide. 22, 24
An NIMH–funded clinical trial of 439 adolescents with major depression found
that a combination of medication and psychotherapy was the most effective
treatment option.25 Other NIMH–funded researchers are developing and testing
ways to prevent suicide in children and adolescents, including early diagnosis
and treatment, and a better understanding of suicidal thinking.
Depression, even the most severe cases, is a highly treatable disorder. As
with many illnesses, the earlier that treatment can begin, the more effective it
is and the greater the likelihood that recurrence can be prevented.
The first step to getting appropriate treatment is to visit a doctor. Certain
medications, and some medical conditions such as viruses or a thyroid disorder,
can cause the same symptoms as depression. A doctor can rule out these
possibilities by conducting a physical examination, interview and lab tests. If
the doctor can eliminate a medical condition as a cause, he or she should
conduct a psychological evaluation or refer the patient to a mental health
professional.
The doctor or mental health professional will conduct a complete diagnostic
evaluation. He or she should discuss any family history of depression, and get a
complete history of symptoms, e.g., when they started, how long they have
lasted, their severity, and whether they have occurred before and if so, how
they were treated. He or she should also ask if the patient is using alcohol or
drugs, and whether the patient is thinking about death or suicide.
Once diagnosed, a person with depression can be treated with a number of
methods. The most common treatments are medication and psychotherapy.
Medication
Antidepressants work to normalize naturally occurring brain chemicals called
neurotransmitters, notably serotonin and norepinephrine. Other antidepressants
work on the neurotransmitter dopamine. Scientists studying depression have found
that these particular chemicals are involved in regulating mood, but they are
unsure of the exact ways in which they work.
The newest and most popular types of antidepressant medications are called
selective serotonin reuptake inhibitors (SSRIs). SSRIs include fluoxetine
(Prozac), citalopram (Celexa), sertraline (Zoloft) and several others. Serotonin
and norepinephrine reuptake inhibitors (SNRIs) are similar to SSRIs and include
venlafaxine (Effexor) and duloxetine (Cymbalta). SSRIs and SNRIs are more
popular than the older classes of antidepressants, such as tricyclics–named for
their chemical structure–and monoamine oxidase inhibitors (MAOIs) because they
tend to have fewer side effects. However, medications affect everyone
differently–no one–size–fits–all approach to medication exists. Therefore, for
some people, tricyclics or MAOIs may be the best choice.
People taking MAOIs must adhere to significant food and medicinal
restrictions to avoid potentially serious interactions. They must avoid certain
foods that contain high levels of the chemical tyramine, which is found in many
cheeses, wines and pickles, and some medications including decongestants. MAOIs
interact with tyramine in such a way that may cause a sharp increase in blood
pressure, which could lead to a stroke. A doctor should give a patient taking an
MAOI a complete list of prohibited foods, medicines and substances.
For all classes of antidepressants, patients must take regular doses for at
least three to four weeks before they are likely to experience a full
therapeutic effect. They should continue taking the medication for the time
specified by their doctor, even if they are feeling better, in order to prevent
a relapse of the depression. Medication should be stopped only under a doctor's
supervision. Some medications need to be gradually stopped to give the body time
to adjust. Although antidepressants are not habit–forming or addictive, abruptly
ending an antidepressant can cause withdrawal symptoms or lead to a relapse.
Some individuals, such as those with chronic or recurrent depression, may need
to stay on the medication indefinitely.
In addition, if one medication does not work, patients should be open to
trying another. NIMH–funded research has shown that patients who did not get
well after taking a first medication increased their chances of becoming
symptom–free after they switched to a different medication or added another
medication to their existing one. 26,27
Sometimes stimulants, anti–anxiety medications, or other medications are used
in conjunction with an antidepressant, especially if the patient has a
co–existing mental or physical disorder. However, neither anti–anxiety
medications nor stimulants are effective against depression when taken alone,
and both should be taken only under a doctor's close supervision.
What are the side effects of antidepressants?
Antidepressants may cause mild and often temporary side effects in some
people, but they are usually not long–term. However, any unusual reactions or
side effects that interfere with normal functioning should be reported to a
doctor immediately.
The most common side effects associated with SSRIs and SNRIs include:
Headache–usually temporary and will subside.
Nausea–temporary and usually short–lived.
Insomnia and nervousness (trouble falling asleep or waking often during
the night)–may occur during the first few weeks but often subside over time
or if the dose is reduced.
Agitation (feeling jittery).
Sexual problems–both men and women can experience sexual problems
including reduced sex drive, erectile dysfunction, delayed ejaculation, or
inability to have an orgasm.
Tricyclic antidepressants also can cause side effects including:
Dry mouth-it is helpful to drink plenty of water, chew gum, and clean
teeth daily.
Constipation-it is helpful to eat more bran cereals, prunes, fruits, and
vegetables.
Bladder problems–emptying the bladder may be difficult, and the urine
stream may not be as strong as usual. Older men with enlarged prostate
conditions may be more affected. The doctor should be notified if it is
painful to urinate.
Sexual problems–sexual functioning may change, and side effects are
similar to those from SSRIs.
Blurred vision–often passes soon and usually will not require a new
corrective lenses prescription.
Drowsiness during the day–usually passes soon, but driving or operating
heavy machinery should be avoided while drowsiness occurs. The more sedating
antidepressants are generally taken at bedtime to help sleep and minimize
daytime drowsiness.
FDA Warning on Antidepressants
Despite the relative safety and popularity of SSRIs and other
antidepressants, some studies have suggested that they may have unintentional
effects on some people, especially adolescents and young adults. In 2004, the
Food and Drug Administration (FDA) conducted a thorough review of published and
unpublished controlled clinical trials of antidepressants that involved nearly
4,400 children and adolescents. The review revealed that 4% of those taking
antidepressants thought about or attempted suicide (although no suicides
occurred), compared to 2% of those receiving placebos.
This information prompted the FDA, in 2005, to adopt a "black box" warning
label on all antidepressant medications to alert the public about the potential
increased risk of suicidal thinking or attempts in children and adolescents
taking antidepressants. In 2007, the FDA proposed that makers of all
antidepressant medications extend the warning to include young adults up through
age 24. A "black box" warning is the most serious type of warning on
prescription drug labeling.
The warning emphasizes that patients of all ages taking antidepressants
should be closely monitored, especially during the initial weeks of treatment.
Possible side effects to look for are worsening depression, suicidal thinking or
behavior, or any unusual changes in behavior such as sleeplessness, agitation,
or withdrawal from normal social situations. The warning adds that families and
caregivers should also be told of the need for close monitoring and report any
changes to the physician. The latest information from the FDA can be found on
their Web site at www.fda.gov.
Results of a comprehensive review of pediatric trials conducted between 1988
and 2006 suggested that the benefits of antidepressant medications likely
outweigh their risks to children and adolescents with major depression and
anxiety disorders.28 The study was funded in part by the National Institute of
Mental Health.
Also, the FDA issued a warning that combining an SSRI or SNRI antidepressant
with one of the commonly-used "triptan" medications for migraine headache could
cause a life-threatening "serotonin syndrome," marked by agitation,
hallucinations, elevated body temperature, and rapid changes in blood pressure.
Although most dramatic in the case of the MAOIs, newer antidepressants may also
be associated with potentially dangerous interactions with other medications.
What about St. John's wort?
The extract from St. John's wort (Hypericum perforatum), a bushy,
wild-growing plant with yellow flowers, has been used for centuries in many folk
and herbal remedies. Today in Europe, it is used extensively to treat mild to
moderate depression. In the United States, it is one of the top-selling
botanical products.
To address increasing American interests in St. John's wort, the National
Institutes of Health conducted a clinical trial to determine the effectiveness
of the herb in treating adults who have major depression. Involving 340 patients
diagnosed with major depression, the eight-week trial randomly assigned
one-third of them to a uniform dose of St. John's wort, one-third to a commonly
prescribed SSRI, and one-third to a placebo. The trial found that St. John's
wort was no more effective than the placebo in treating major depression.29
Another study is looking at the effectiveness of St. John's wort for treating
mild or minor depression.
Other research has shown that St. John's wort can interact unfavorably with
other medications, including those used to control HIV infection. On February
10, 2000, the FDA issued a Public Health Advisory letter stating that the herb
appears to interfere with certain medications used to treat heart disease,
depression, seizures, certain cancers, and organ transplant rejection. The herb
also may interfere with the effectiveness of oral contraceptives. Because of
these potential interactions, patients should always consult with their doctors
before taking any herbal supplement.
Psychotherapy
Several types of psychotherapy–or "talk therapy"–can help people with
depression.
Some regimens are short–term (10 to 20 weeks) and other regimens are
longer–term, depending on the needs of the individual. Two main types of
psychotherapies–cognitive–behavioral therapy (CBT) and interpersonal therapy (IPT)-have
been shown to be effective in treating depression. By teaching new ways of
thinking and behaving, CBT helps people change negative styles of thinking and
behaving that may contribute to their depression. IPT helps people understand
and work through troubled personal relationships that may cause their depression
or make it worse.
For mild to moderate depression, psychotherapy may be the best treatment
option. However, for major depression or for certain people, psychotherapy may
not be enough. Studies have indicated that for adolescents, a combination of
medication and psychotherapy may be the most effective approach to treating
major depression and reducing the likelihood for recurrence.25 Similarly, a
study examining depression treatment among older adults found that patients who
responded to initial treatment of medication and IPT were less likely to have
recurring depression if they continued their combination treatment for at least
two years.21
Electroconvulsive Therapy
For cases in which medication and/or psychotherapy does not help alleviate a
person's treatment–resistant depression, electroconvulsive therapy (ECT) may be
useful. ECT, formerly known as "shock therapy," once had a bad reputation. But
in recent years, it has greatly improved and can provide relief for people with
severe depression who have not been able to feel better with other treatments.
Before ECT is administered, a patient takes a muscle relaxant and is put
under brief anesthesia. He or she does not consciously feel the electrical
impulse administered in ECT. A patient typically will undergo ECT several times
a week, and often will need to take an antidepressant or mood stabilizing
medication to supplement the ECT treatments and prevent relapse. Although some
patients will need only a few courses of ECT, others may need maintenance ECT,
usually once a week at first, then gradually decreasing to monthly treatments
for up to one year.
ECT may cause some short-term side effects, including confusion,
disorientation and memory loss. But these side effects typically clear soon
after treatment. Research has indicated that after one year of ECT treatments,
patients showed no adverse cognitive effects.30
What efforts are underway to improve treatment?
Researchers are looking for ways to better understand, diagnose and treat
depression among all groups of people. New potential treatments are being tested
that give hope to those who live with depression that is particularly difficult
to treat, and researchers are studying the risk factors for depression and how
it affects the brain. NIMH continues to fund cutting–edge research into this
debilitating disorder.
For more information on NIMH-funded research on depression, visit
the NIMH website.
If you know someone who is depressed, it affects you too. The first and most
important thing you can do to help a friend or relative who has depression is to
help him or her get an appropriate diagnosis and treatment. You may need to make
an appointment on behalf of your friend or relative and go with him or her to
see the doctor. Encourage him or her to stay in treatment, or to seek different
treatment if no improvement occurs after six to eight weeks.
To help a friend or relative:
Offer emotional support, understanding, patience and encouragement.
Engage your friend or relative in conversation, and listen carefully.
Never disparage feelings your friend or relative expresses, but point
out realities and offer hope.
Never ignore comments about suicide, and report them to your friend's or
relative's therapist or doctor.
Invite your friend or relative out for walks, outings and other
activities. Keep trying if he or she declines, but don't push him or her to
take on too much too soon. Although diversions and company are needed, too
many demands may increase feelings of failure.
Remind your friend or relative that with time and treatment, the
depression will lift.
If you have depression, you may feel exhausted, helpless and hopeless. It may
be extremely difficult to take any action to help yourself. But it is important
to realize that these feelings are part of the depression and do not accurately
reflect actual circumstances. As you begin to recognize your depression and
begin treatment, negative thinking will fade.
To help yourself:
Engage in mild activity or exercise. Go to a movie, a ballgame, or
another event or activity that you once enjoyed. Participate in religious,
social or other activities.
Set realistic goals for yourself.
Break up large tasks into small ones, set some priorities and do what
you can as you can.
Try to spend time with other people and confide in a trusted friend or
relative. Try not to isolate yourself, and let others help you.
Expect your mood to improve gradually, not immediately. Do not expect to
suddenly "snap out of" your depression. Often during treatment for
depression, sleep and appetite will begin to improve before your depressed
mood lifts.
Postpone important decisions, such as getting married or divorced or
changing jobs, until you feel better. Discuss decisions with others who know
you well and have a more objective view of your situation.
Remember that positive thinking will replace negative thoughts as your
depression responds to treatment.
If you are unsure where to go for help, ask your family doctor. Others who
can help are listed below.
Mental Health Resources:
Mental health specialists, such as psychiatrists, psychologists, social
workers, or mental health counselors
Health maintenance organizations
Community mental health centers
Hospital psychiatry departments and outpatient clinics
Mental health programs at universities or medical schools
State hospital outpatient clinics
Family services, social agencies or clergy
Peer support groups
Private clinics and facilities
Employee assistance programs
Local medical and/or psychiatric societies
You can also check the phone book under "mental health," "health,"
"social services," "hotlines," or "physicians" for phone numbers and
addresses. An emergency room doctor also can provide temporary help and can
tell you where and how to get further help.
If you are thinking about harming yourself, or know someone who is, tell
someone who can help immediately.
Call your doctor.
Call 911 or go to a hospital emergency room to get immediate help or ask
a friend or family member to help you do these things.
Call the toll-free, 24-hour hotline of the National Suicide Prevention
Lifeline at 1-800-273-TALK (1-800-273-8255); TTY: 1-800-799-4TTY (4889) to
talk to a trained counselor.
Make sure you or the suicidal person is not left alone.
Information from NIMH is available in multiple formats. You can browse
online, download documents in PDF, and order paper brochures through the mail.
If you would like to have NIMH publications, you can order them online at
www.nimh.nih.gov. If you do not have Internet access and wish to have
information that supplements this publication, please contact the NIMH
Information Center at the numbers listed below.
Please check the NIMH Web site for the
most up-to-date information on this topic.
National Institute of Mental Health
Science Writing, Press & Dissemination Branch
6001 Executive Boulevard
Room 8184, MSC 9663
Bethesda, MD 20892-9663
Phone: 301-443-4513 or
1-866-615-NIMH (6464) toll-free
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FAX: 301-443-4279
E-mail: nimhinfo@nih.gov
Web site: http://www.nimh.nih.gov
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This publication is in the public domain and may be reproduced or copied
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NIMH envisions a world in
which mental illnesses are prevented and cured. The mission of NIMH is
to transform the understanding and treatment of mental illnesses through basic
and clinical research, paving the way for prevention, recovery and cure. For the
Institute to continue fulfilling this vital public health mission, it must
foster innovative thinking and ensure that a full array of novel scientific
perspectives are used to further discovery in the evolving science of brain,
behavior, and experience. In this way, breakthroughs in science can become
breakthroughs for all people with mental illnesses.